Background and Recommended Change in Scope (CIS) Instructions and Procedures for Federally Qualified Health Centers
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Background and Recommended Change in Scope (CIS)
Instructions and Procedures for Federally Qualified Health Centers
Federally Qualified Health Centers (FQHCs) are community-based health care providers, defined
under Section 1905(l)(2)(B) of the Social Security Act, to provide primary care services in
underserved areas and populations. They must meet a stringent set of requirements which
include the provision of a mandatory scope of services, acceptance of all patients regardless of
insurance status, offering care on a sliding fee scale based on ability to pay and having a governing
board that includes patients.
Provisions Related to Changes in Scope for FQHCs
FQHC designation and program compliance is overseen by the Bureau of Primary Care within the
Health Resources and Services Administration (HRSA) within the Department of Health and
Human Services. Federal health center program requirements include the obligation by FQHCs
to initiate changes in scope as necessary to maintain an accurate “scope of project.” Additionally,
Medicaid regulations require states establish procedures for FQHCs to receive adjustments in
established per visit reimbursement rates as needed to account for changes in the type, intensity,
duration and amount of services.
1. HRSA Scope of Project
Once an organization is designated by HRSA as a federally qualified health center, each health
center must document and maintain its “Scope of Project.” The scope of project defines the
HRSA approved service sites, services, providers, service area(s) and target populations which
are supported (wholly or in part) under the total budget approved as part of the federal grant
program. Health centers document the scope of project through a series of forms, see
attached Forms 5A, B, and C. Health centers are required under federal regulation to maintain
the scope of project and to initiate changes in scope as needed to ensure the required
elements that comprise the scope of project are accurate. The accuracy of the scope of
project, and related changes in scope as necessary are required for several primary purposes:
a. To establish required services (5A) provided at approved sites (5B) and whether the
services are provided directly, by referral, or under contract with other providers,
sites, providers, service areas and target populations for which a health center can
use federal grant funds to cover;
b. To establish the scope of eligibility for coverage of the health center through the
Federal Torts Claims Act (FTCA) which considers FQHCs as federal entities/employees
for purposes of defense against malpractice;
c. To establish eligibility as a covered entity for purposes of the 340B Drug Discount
Program;
d. To establish eligibility for reimbursement as a federally qualified health center under
Medicare and Medicaid; and
e. To establish the scope of eligibility for additional federal benefits including, but not
limited to, placement of providers through the National Health Service Corps.Procedures to process changes in scope required by HRSA are not related to nor do they
contain the requisite level of detail necessary to set rates and/or adjust a health center’s
Medicaid PPS rate in response to changes in type, intensity, duration, and amount of services
provided to Medicaid enrollees. The HRSA CIS requirements are indicators of changes in
service types that may dictate a Medicaid CIS but are not all inclusive or the only reason a
Medicaid CIS may occur.
2. Medicaid Change in Scope
Benefits Improvement and Protection Act (BIPA), 2000, Section 702 mandated health center
reimbursement be made on a per visit basis through a prospective payment system. Baseline
encounter rates were established based on the reasonable and related cost of providing
Medicaid covered services in FY 1999 and 2000, see §1902(bb)(2) of the Social Security Act
(SSA). Additionally, BIPA required States to pay health centers a per visit rate that is “adjusted
to take into account any increase or decrease in the scope of such.” Implicit in the
requirement is that any change meet two elements: first, there must be a change and second,
there must be a cost impact.
The Centers for Medicare and Medicaid Services (CMS) has further defined the State’s change
in scope provisions should include changes in the “type, intensity, duration and/or amount”
of services (Attachment A, September 12, 2001 CMS Letter with attached BIPA Q/As, and
specifically, Q.20). These terms provide a requirement that rates be adjusted if the cost
structure of an FQHC changes due to changes in the service delivery. CMS elaborates:
A change in scope of FQHC/RHC services shall occur if: (1) the center/clinic has added or
has dropped any service that meets the definition of FQHC FQHC/RHC services as provided
in section 1905(a)(2)(B) and (C); and (2) the service is included as a covered Medicaid
service under the Medicaid state plan approved by the Secretary. A change in the ‘scope
of services’ is defined as a change in the type, intensity, duration and/or amount of
services. A change in the cost of a service is not considered in and of itself a change in the
scope of services. In making such an adjustment, state agencies must add on the cost of
new FQHC/RHC services even if these services do not require a face-to-face visit with a
FQHC/RHC provider, e.g., laboratory, x-rays, drugs, outreach, case management,
transportation, etc.
Medicaid’s change in scope policy is reflected in the Alabama Medicaid State Plan. The
relevant portion of Alabama’s State Plan is contained in Transmittal No. AL-03-04, which has
an effective date of July 1, 2003. Alabama notes that the PPS rate will be adjusted to take into
account any increase (or decrease) in the scope of services furnished by the FQHC during that
fiscal year. As for further details with respect to implementation of change in scope
procedures, the State Plan provides:
A new FQHC provider or a provider who has a Medicaid approved change in scope
of services, can request reimbursement based on their facilities submitted
operating budget. After the actual cost report is received and desk reviewed for
the budget period, an actual encounter rate will be determined. In this event, theFQHC may be subject to a retroactive adjustment based on the difference between
budgeted and actual allowable costs. This difference may be subject to settlement
within thirty (30) days after written notification by Medicaid to the provider of the
amount of the difference.
The related State regulation found at section 560X56.04 of the Alabama Medicaid Agency
Administrative Code states that the PPS rate will be adjusted to take into account any increase
(or decrease) in the scope of services furnished in that fiscal year. The Medicaid Provider Billing
Manual, Chapter 16, does not address the procedure for requesting and/or processing change in
scope requests.
As discussed with staff on March 30, APHCA agrees that a written procedure that describes the
change in scope adjustment process is necessary to provide instructions that align with federal
law and Medicaid’s existing policy as reflected in the State Plan and Administrative Code. For
your review and consideration, please find APHCA’s proposal for change in scope instructions
and related procedures.
APHCA appreciates the opportunity to submit our recommendations and looks forward to
answering questions and engaging in additional dialogue to move forward.Proposed Instructions: Medicaid in Consideration of Change in Scope Requests
The instructions that follow are intended to assist FQHCs in their submission of a Change in
Scope (CIS) cost report and request. This information will be used to determine if the CIS project
first meets the CIS eligibility criteria defined below. If the CIS meets the eligibility requirements,
then the remaining financial and statistical data will be used to determine the FQHCs new PPS
rate.
For FQHC’s seeking a change in the scope, the FQHC’s per-encounter PPS rate will be adjusted to
account for increases or decreases in the scope of services subject to the following:
A. The rate adjustment is attributable to an increase or decrease in the scope of the services as
defined below in Section 1.
B. To be considered, any costs supporting the rate adjustment must be allowable under the
Medicare reasonable cost principles set forth in 42 C.F.R. § 413.
C. The change meets regulatory compliance as it relates to the operation of FQHC services
provided under the Alabama Medicaid Program.
D. A change in costs alone without a qualifying change in the scope of services as defined in
Section 1 does not qualify for a rate adjustment.
Additionally, all CIS requests must meet regulatory compliance as required by state law or
federal law as it relates to the operation of FQHC services provided under the Alabama
Medicaid Program.
1. Medicaid Change in Scope
A change in the scope of services is defined as a change in the type, intensity, duration, or
amount of services. Examples, which can occur alone or cumulatively, are the following:
A. Type: the addition or deletion of a Medicaid-covered ambulatory service;
B. Intensity: a change in the type, quality and/or quantity of services offered in an
average visit such that the average patient receives a different array of services than
the service mix patients received when the PPS rate was last set. Examples include,
but are not limited to changes caused by new statutory or regulatory requirements,
applicable technology and/or medical practices utilized by the FQHC, changes in
types of patients served, including, but not limited to, populations with HIV/AIDS,
populations with other chronic diseases, or homeless, elderly, migrant, or other
special populations that require more intensive and frequent care; the introduction
or expansion of services performed, and changes in the quantity of labor and
materials consumed by patients during an average encounter;
C. Duration: a change in the average length of time it takes FQHC providers to complete
an average patient visit due to changing circumstances including, but not limited to
demographic changes, adoption of new accredited models of care, standards of care,
and/or new disease management programs; and/or
D. Amount: an increase or decrease in the quantity of services that an average patient
receives in an average visit including, but not limited to the addition of outreach and
case management services or improvements in technology or facilities that result inincreased or improved services to FQHC’s patients.
2. Change in Scope Request
To request a change in scope of a service as described in Section 1:
A. HCs will notify the state in writing, including a detailed description and
documentation of the service change. For the addition of a service, the description
should include the service the HC is adding, the location(s), the date the HC began,
or will begin providing the service, and a brief description of how the new service
will benefit the patient population. For a change in intensity, duration, or amount,
the description should include the service change, the location(s), a description of
how the average visit has changed from when the HC’s rate was set, along with
relevant supporting documentation, and how the change has benefitted the patient
population.
The cost increases or decreases included in a CIS request will be subject to
reasonable cost criteria as prescribed in 42 CFR Part 405, Subpart X, or applicable
federal regulation.
B. The HC can submit a prospective or a historical CIS request to Medicaid.
i. Prospective: The center will submit a prospective cost report which must
include a 12-month prospective estimate of expenses and encounters.
Prospective is defined as a service that will begin within the next 90 days or
has been implemented less than six months prior. Included in this submittal
will be the agency’s 12-month historical costs and encounters plus the
projected costs and encounters relating to the change. Once the prospective
rate is approved, the HC will then have 90 days to implement the change is
scope as demonstrated by a notice to the state that the change has been
implemented.
ii. Historical: The second option is a historical change in scope cost report where
the HC submits actual expenses. The approved changes must be in effect for
at least 6 months.
C. Requests should include a narrative outlining the changes that support the
submission, reason for implementation, and benefit to the patient, and cost report
packet outlined in Section 4.
D. The State will review the submitted documentation and notify the HC within 30 days
whether the proposed change meets criteria for a change in scope. This is not a review
of the cost and encounter data but a determination of whether the definition of a CIS
is met.
E. Implementation of the Rate Change:
i. Prospective: If a prospective CIS is approved, the state will update the
center’s PPS rate to the rate submitted by the center in the request for a CIS.
This is an interim rate and will be reconciled to the final rate (see Section 5
below). This update will occur on the first day of the month following the
approval. The state has 30 days after receipt of the CIS request to approve
the requested CIS.ii. Historical: If a historical CIS is approved, the state will update the center’s PPS
rate to an interim rate submitted by the center in the request for a CIS. This
interim rate update will occur on the first day of the month following the
approval. The state has 30 days after the receipt of the CIS request to
approve the requested CIS.
F. Upon approval by the State, the HC will continue receiving the current PPS rate for
the service until the cost of the change in scope can be determined as described in
Sections 4 and 5. HCs will receive PPS payments for the service retroactively back to
the date of change in scope application.
G. A HC may appeal a denial of a request for a change in scope or a rate adjustment due
to a change in the scope of services.
H. If the state does not respond to a request for a CIS according to the timeline noted
above the request will be automatically approved.
I. For prospective cost reports, there will be a reconciliation process to reconcile the
estimated expenses and encounters to actual expenses and encounters after the
change in scope of service has been fully implemented for a full fiscal year. The final
rate setting and reconciliation process will be determined as described in Sections 4
and 5.
J. If a service has been eliminated, HC will notify the State that they have discontinued
a given service. The cost of the change in scope will be determined as described in
Sections 4 and 5.
3. PPS Rate Adjustments
The HC’s per-encounter PPS rate will be adjusted to account for increases or decreases in the
scope of services subject to the following:
A. The rate adjustment is attributable to an increase or decrease in the scope of the
services as defined in Section 1.
B. To be considered, any costs supporting the rate adjustment must be allowable under
the Medicare reasonable cost principles set forth in 42 C.F.R. § 413.
C. A change in costs alone without a qualifying change in the scope of services as defined
in Section 1 does not qualify for a rate adjustment.
4. Final Cost Report
A. Prospective: HCs will submit the reconciling cost report packet (first full year) to the
state no later than 120 days after the end of the fiscal year. This packet will include
the cost report file, trial balance, depreciation schedule, schedule listing allocations,
documentation for reclassification, and adjustments for the most recent full year to
determine an average cost per visit. The supporting documentation listed above will
be utilized to verify the information reported on the cost report. Total costs are
divided by total visits for the cost report period. The State shall calculate the cost per
visit based on the reasonable cost of providing Medicaid covered, ambulatory
services. This will determine their prospective payment system (PPS) rate.
B. A change in costs alone without a qualifying change in scope of services as definedin section 1 above does not qualify for a rate adjustment.
C. Historical: HCs will submit the cost report packet aligned with the last completed
fiscal year to the state at such time they request the CIS. This will include at least 6
months of costs and is due no later than 120 days after the end of the fiscal year.
This packet will include the cost report file, trial balance, depreciation schedule,
schedule listing allocations, documentation for reclassification, and adjustments for
the most recent full year to determine an average cost per visit cost. The supporting
documentation listed above will be utilized to verify the information reported on the
cost report. Total costs are divided by total visits for the cost report period. The State
shall calculate the cost per visit based on the reasonable cost of providing Medicaid
covered, ambulatory services. This will determine their prospective payment system
(PPS) rate.
5. Cost Report Reconciliation
A. Prospective and Historical Changes in Scope:
i. At the end of the HC’s first full fiscal year that includes the CIS, a rate
reconciliation will occur.
ii. The HC will be required to submit a Medicaid cost report and all other
supporting documents as outlined in Section 4(A).
iii. The State will then compare the prospective rate that was approved based
upon the estimated costs and encounters to the rate as calculated based
upon the actual expenses and encounters.
iv. The state will complete this review no later than 10 months after the HC’s
fiscal year end.
v. The HC’s rate at this point can either increase or decrease. If the rate
increases, then the State will reimburse the HC retroactively to when the CIS
was implemented. If the rate decreases, then the HC will submit payment
back to the State in the amount of the decrease retroactively to when the CIS
was implemented.
vi. Reconciliation will be based on the final, settled rate, applied to each fiscal
year the interim rate covered. For each prior year, the final rate will be
adjusted backwards by the MEI. The MEI-adjusted rate times the encounters
for that fiscal year minus the amount paid will equal the amount of
reconciliation for that fiscal year.Form 5A: Services Provided
OMB No.: 0915-0285. Expiration Date: 3/31/2023
DEPARTMENT OF HEALTH AND HUMAN FOR HRSA USE ONLY
SERVICES Grant Number Application
Health Resources and Services Administration Tracking #
FORM 5A: SERVICES PROVIDED
(REQUIRED SERVICES)
This form will pre-populate for competing continuation applicants. For more information, refer to the Service
Descriptors for Form 5A: Services Provided and the Column Descriptors for Form 5A: Services Provided.
Service Delivery Methods
Formal Written
Formal Written
Referral
Direct Contract/ Agreement
Service Type Arrangement
(Health Center pays) (Health Center
(Health Center
pays)
DOES NOT pay)
General Primary Medical Care
Diagnostic Laboratory
Diagnostic Radiology
Screenings
Coverage for Emergencies During and
After Hours
Voluntary Family Planning
Immunizations
Well Child Services
Gynecological Care
Obstetrical Care
• Prenatal Care
• Intrapartum Care (Labor &
Delivery)
• Postpartum Care
Preventive Dental
Pharmaceutical Services
HCH Required Substance Use
Disorder Services
Case Management
Eligibility Assistance
Health Education
Outreach
Transportation
TranslationPage 2 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES FOR HRSA USE ONLY
Health Resources and Services Administration Grant Number Application Tracking
Number
FORM 5A: SERVICES PROVIDED
(ADDITIONAL SERVICES)
Service Delivery Methods
Formal Written
Formal Written
Direct Referral
Contract/ Agreement
Service Type (Health Center Arrangement
(Health Center
pays) (Health Center
pays)
DOES NOT pay)
Additional Dental Services
Behavioral Health Services
• Mental Health Services
• Substance Use Disorder Services
Optometry
Recuperative Care Program Services
Environmental Health Services
Occupational Therapy
Physical Therapy
Speech-Language Pathology/Therapy
Nutrition
Complementary and Alternative
Medicine
Additional Enabling/Supportive
Services
Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver
comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program
application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding
recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is
valid until 3/31/2023. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public
Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1 hour per
response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or
paperwork@hrsa.gov.
Instructions
Refer to the Form 5A Service Descriptors for descriptions of the required and additional
services and the Form 5A Column Descriptors for descriptions of the three service delivery
methods used by health centers.
You must propose to make General Primary Medical Care available directly (Column I)
and/or through a formal written contractual agreement in which you pay for the service
(Column II) to comply with eligibility requirement 3.
Competing continuation applicants:
This form will pre-populate from your current scope of project and cannot be modified through
this application. For this form to accurately pre-populate, when you complete the SF-424 in
Page 2 of 3Page 3 of 3
Grants.gov, select Continuation for box 2 and provide your grant number for box 4. Failure to
correctly complete the SF-424 may result in delayed HRSA Electronic Handbooks (EHBs)
application access.
Changes in services require prior approval through a Change in Scope request submitted in
EHBs. If the pre-populated data do not reflect recently approved changes, click the Refresh
from Scope button in EHBs to display the latest scope of project. Refer to the Scope of Project
documents and resources for details about defining and changing your scope.
New and competing supplement applicants:
Complete this form based only on the scope of project included in this application for the
proposed service area. Identify how services will be provided (i.e., directly, through a formal
written contract/agreement in which you pay for the service, and/or through a formal written
referral arrangement). Complete this form only once, regardless of the number of sites
proposed. If your application is funded, only the services listed on this form will be in your
approved scope of project, regardless of what is described elsewhere in your application.
Reminders:
• You must provide all required services without regard for ability to pay and on a sliding fee
discount schedule.
• All contracts/referral arrangements for services must be formal written contracts/referral
arrangements.
• Additional services are not required, but if you would like to propose additional services,
they must be included on this form to be in the scope of project.
For more information, refer to Chapter 4: Required and Additional Health Services of the
Compliance Manual.
Special considerations for competing supplement applicants:
• All services in your current scope of project must be accessible to patients in the service
area proposed in this application.
• If new services are proposed in this application and it is funded, they must be accessible
to both current and proposed patients.
Page 3 of 3Form 5B: Service Sites
OMB No.: 0915-0285. Expiration Date: 3/31/2023
FOR HRSA USE ONLY
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Grant Application Tracking
Health Resources and Services Administration
Number Number
FORM 5B: SERVICE SITES
Note: This form will pre-populate for competing continuation applicants.
New and Competing Supplement Applicants: If you are requesting funding to target the general
underserved community (CHC), residents of public housing (PHPC), or people experiencing
homelessness (HCH), you must propose at least one new Service Delivery site or Administrative/Service
Delivery site with the Location Type as 'Permanent' and operating for at least 40 hours.
If you are proposing to serve ONLY migrant and seasonal agricultural workers (MHC), you must propose
at least one new Service Delivery site or Administrative/Service Delivery site with the Location Type as
'Permanent' or 'Seasonal' and operating for at least 40 hours.
Site Qualification Criteria
1. Is the site an Admin-only site?
If Yes, the site is an Admin-only site, select ‘Not Applicable’ for [_] Yes [_] No
questions a through d below. If No, the site is a Service Delivery
site, answer questions a through d Yes or No.
a. Are/will health center visits be generated by documenting in
the patients’ records face-to-face contacts between patients [_] Yes [_] No [_] Not Applicable
and providers?
b. Do/will providers exercise independent judgment in the
provision of services to the patient? [_] Yes [_] No [_] Not Applicable
c. Are/will services be provided directly by or on behalf of the
grantee, whose governing board retains control and authority [_] Yes [_] No [_] Not Applicable
over the provision of the services at the location?
d. Are/will services be provided on a regularly scheduled basis
(e.g., daily, weekly, first Thursday of every month)? [_] Yes [_] No [_] Not Applicable
2. Is the site a Domestic Violence (Confidential) shelter?
Select Yes for this question only if the site being added is a
[_] Yes [_] No [_] Not Applicable
confidential site serving victims of domestic violence and the
site address cannot be published due to the necessity to
protect the location of the domestic violence shelter.Site Information
Site Physical Address
(Ensure your address
contains the
appropriate unique
suite, building, or other
notation, if appropriate.
Site Name
If the address displayed
does not contain this
information, select
Change Physical
Location and update, as
appropriate)
[_] Administrative/Service
Delivery Site
Site Type Site Phone Number
[_] Service Delivery Site
[_] Administrative Site
Web URL
The following fields are required for “Service Delivery” and “Administrative/Service Delivery” site
types:
[_] Permanent [_] All Other Clinic
[_] Seasonal Types
Location Type [_] Mobile Site Setting [_] Hospital
[_] Migrant Voucher [_] School
[_] Intermittent
Read-only for sites
Date Site was Added to already in scope and
Site Operational Date mm/dd/yyyy
Scope disabled when adding a
new site
[_] This site is neither
permanent nor seasonal
per CMS (i.e., does not
require unique FQHC
Medicare Billing Number)
[_] Health center does
FQHC Site Medicare
not/will not bill under the
Billing Number
FQHC Medicare system (Required if ‘This site
FQHC Site Medicare at this site has a Medicare billing
Billing Number Status [_] Number is pending; number’ is selected in
application for this site 'FQHC Site Medicare
has been submitted to Billing Number Status'
CMS field)
[_] Application for this
site has not yet been
submitted to CMS
[_] This site has a
Medicare billing number
FQHC Site National Total Hours of
Provider Identification Operation (when
(NPI) Number patients will be served
(Optional field) per week)
Page 2 of 4Months of Operation
Service Area Zip Codes
Number of Contract
Service Delivery
Number of Intermittent
Locations
Sites (Required only for
(Required only for
‘Intermittent Site’ Type)
‘Migrant Voucher
Screening’ Site Type)
Site Operated by [_] Health Center/Applicant [_] Subrecipient [_] Contractor
Subrecipient or Contractor Information
(Required only if 'Subrecipient’ or ‘Contractor' is selected in 'Site Operated By' field)
Subrecipient/Contractor Organization Name
Subrecipient/Contractor Organization Physical Site
Address
Subrecipient/Contractor EIN
Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver
comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center
Program application forms provide essential information to HRSA staff and objective review committee panels for application
evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information
collection is 0915-0285 and it is valid until 3/31/2023. This information collection is mandatory under the Health Center Program
authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of
information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data
sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600
Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.
Instructions
Competing continuation applicants:
This form will pre-populate from your current scope of project and cannot be modified through
this application. For this form to accurately pre-populate, when you complete the SF-424 in
Grants.gov, select Continuation for box 2 and provide your grant number for box 4. Failure to
correctly complete the SF-424 may result in delayed HRSA Electronic Handbooks (EHBs)
application access.
Changes in sites require prior approval through a Change in Scope request submitted in EHBs.
If the pre-populated data do not reflect recently approved changes, click the Refresh from
Scope button in EHBs to display the latest scope of project. Refer to the Scope of Project
documents and resources for details about defining and changing your scope.
New and competing supplement applicants:
Complete this form for each administrative, service delivery, and administrative/service delivery
site based only on the scope of project included in this application for the proposed service
area. If your application is funded, only the sites on this form will be in your approved scope of
project, regardless of what is described elsewhere in your application.
Page 3 of 4You must propose at least one new full-time permanent service delivery site, or
administrative/service delivery site, 1 located in the proposed service area to comply with
eligibility requirement 5. Provide requested data, including a verifiable street address, for each
proposed service site.
You must enter zip codes in the Service Area Zip Codes field for service delivery sites
and administrative/service delivery sites 2 to comply with Eligibility Requirement 4c. You
must include:
1) A combination of SAAT Service Area Zip Codes where zip code patient percentages
total at least 75 percent, or
2) All SAAT Service Area Zip Codes for the proposed service area, if the sum of all zip
code patient percentages is less than 75 percent.
Zip codes that you enter for administrative-only sites will not be considered.
Special consideration for competing supplement applicants:
After proposing at least one new full-time permanent service delivery site located in the
proposed service area, sites from your current scope of project may be selected to the extent
that they will provide services to the proposed new patients.
1
If you propose to serve only migratory and seasonal agricultural workers (MHC), you may propose a full-
time seasonal (rather than permanent) service delivery site.
2
HRSA considers service area overlap when making funding determinations for new and competing
supplement applicants if zip codes are proposed on Form 5B: Service Sites beyond those listed in the
SAAT. For more information about service area overlap, refer to Policy Information Notice 2007-09.
Page 4 of 4Form 5C: Other Activities/Locations
OMB No.: 0915-0285. Expiration Date: 3/31/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES FOR HRSA USE ONLY
Health Resources and Services Administration Grant Number Application
Tracking Number
Form 5C: OTHER ACTIVITIES/LOCATIONS
Activity/Location Information
[_] Immunizations
[_] Hospital Admitting
[_] Medical Rounds
[_] Home Visits
Type of Activity (select one) [_] Health Fairs
[_] Non-Clinical Outreach
[_] Portable Clinical Care
[_] Health Education
[_] Other – Please Specify:
Frequency of Activity (max 600 characters)
Description of Activity (max 600 characters)
Type of Location(s) where Activity is
Conducted
Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver
comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center
Program application forms provide essential information to HRSA staff and objective review committee panels for application
evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information
collection is 0915-0285 and it is valid until 3/31/2023. This information collection is mandatory under the Health Center Program
authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of
information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data
sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600
Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.
Instructions
Competing continuation applicants:
This form will pre-populate from your current scope of project and cannot be modified through
this application. For this form to accurately pre-populate, when you complete the SF-424 in
Grants.gov, select Continuation for box 2 and provide your grant number for box 4. Failure to
correctly complete the SF-424 may result in delayed HRSA Electronic Handbooks (EHBs)
application access.
Changes in other activities/locations require prior approval through a Change in Scope request
submitted in EHBs. If the pre-populated data do not reflect recently approved changes, click the
Refresh from Scope button in EHBs to display the latest scope of project. Refer to the Scopeof Project documents and resources for details about defining and changing your scope.
New and competing supplement applicants:
Complete this form for other activities/locations (e.g., home visits, health fairs) based only on the
scope of project included in this application for the proposed service area. List only
activities/locations that:
1) Do not meet the definition of a service delivery site,
2) Are conducted on an irregular timeframe/schedule, and/or
3) Offer a limited activity from within the full complement of health center activities in the
scope of project. 1
If your application is funded, only the other activities/locations on this form will be in your
approved scope of project, regardless of what is described elsewhere in your application.
1
Refer to Scope of Project for more information.
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